INTRODUCTION

“Whether we are shopping, riding the subway, or eating in a restaurant, all of which are casual day to day social encounters, there is the initial stare, then the look away, before a second, furtive glance inevitably puts the beheld immediately in a separate class. For those who experience this discrimination, the question of the moral justification of surgery to increase societal acceptance is merely rhetorical. There can be no greater wish than to melt into the crowd or to walk into a room unnoticed”

A transwoman wants to be accepted by society as a woman without attracting attention. She wants the confidence to go about her normal business without the anxiety that she might be identified as a man trying to be a woman or a transwoman. She wants to feel confident about herself as a woman and not to experience self- doubt.

There are several factors that can help a transwoman to portray her sense of herself as a woman such as hairstyle, deportment, behaviour and voice but there is no doubt that a feminine body appearance improves the transwoman’s chance of society recognizing her as female. Facial appearance is the most obvious component of body habitus by which society recognizes an individual as male or female.

Of the many medical interventions that a transwoman might accept in order to confirm her female sex, facial surgery ranks high on the list.

WHY WOULD I WANT FACIAL FEMINISATION SURGERY?

The reason any transwoman would put herself through surgery is to gain acceptance as a woman by society. She does not want to walk down the street and feel self-conscious about her appearance. She wants to blend in and not be noticed. There are other surgical procedures including genital sex reassignment surgery (GRS), the operation most commonly associated with sexual transition, but this is not visible. GRS is undoubtedly a major undertaking and constitutes a significant change in a person’s body but in the day to day social environment it will have little impact on the way that society identifies a person’s sex.

There are many transwomen who pass as a female without any surgical interventions and feel quite comfortable in their own skin. The purpose behind any medical intervention for transgender people is to help them be accepted by society in their chosen gender but if a transwoman already feels comfortable then clearly there is no need to seek out treatment to change their facial appearance.

HOW DO I FIND ADVICE ABOUT FACIAL FEMINIZING SURGERY?

Many individuals seeking help with transitioning seem bewildered and frustrated at not readily finding the help and guidance they need to achieve their objectives. Consequently, these individuals devise their own clinical pathway. There should be a better way.

It is better to seek advice from the professionals and to that end a network of Gender Identity Clinics have become established over the years. Your first port of call should be your GP. Your GP may have little knowledge of gender identity issues but it is your GP’s responsibility to facilitate your treatment and they should refer you to a gender identity clinic. Your GP should help you access services in a timely fashion. Following an appointment at a gender identity clinic you should have the benefit of a multidisciplinary team of clinicians who will offer a holistic approach to your problem with referral to doctors from different specialties with a knowledge of gender identity disorders.

WILL I BE ELIGIBLE FOR FACIAL FEMINISING SURGERY ON THE NHS?

NHS England has developed a protocol for managing Transmen and Transwomen and any of the official gender identity clinics in the country will advise you on how to access various treatments which are considered core components of the transitioning process. An example of core surgery includes gender reassignment surgery. At the present time, Facial Feminizing Surgery is not considered a core treatment although you can apply to your Clinical Commissioning Group for special consideration.

In reality though the individual tends to be left to their own devices in sourcing a suitable surgeon and your likely to have to fund your facial feminizing surgery yourself. Your GP may be able to advise or you can ask at your GIC. Many transwomen choose a surgeon by personal recommendation.

DO I NEED A REFERRAL FROM MY GIC OR GP FOR FACIAL FEMINISING SURGERY?

Many transwomen, understandably, struggle to get started with the transitioning process because of they lack the confidence to make that first step into the public eye dressed as a female. Sometimes they see facial feminising surgery as the first step.

There is no protocol that governs facial surgery and there is no requirement to go through a period of living as a woman (often referred to as a real-life experience), before consulting a specialist about facial feminizing surgery.

However most responsible surgeons will ask for confirmation of a diagnosis from a physician specializing in gender issues, before committing to major facial surgery.

WHAT IS THE DIFFERENCE BETWEEN A MALE AND A FEMALE FACE?

We take for granted that there is a difference between a male and female face without really ever considering the difference or why there should be one.

Sex differences relate to reproduction and the anatomical differences involved in reproduction are termed primary sex characteristics whereas those characteristics which are not directly related to reproduction but relate to courtship are termed secondary sex characteristics. The facial features which we recognize as male or female are secondary sex characteristics and they start to become evident at puberty.

Your face is arguably the most important component of your body habitus which identifies your sex to the casual observer but what is the difference between a female and a male face? To help understand this consider the child’s face before puberty. There is little to distinguish the female face from the male face but during adolescence there is a rapid change in the male face but not nearly so much in the female face. The male face grows downwards and forwards at puberty. The brow becomes more protuberant, the face larger with a larger lower third of the face, a more prominent nose and heavier facial bones as well as facial hair, thicker skin and male pattern hairline.

The facial skeleton

The difference in shape between the male and female face is largely attributable to the changes that occur to the bone structure of the male face at puberty and during adolescence. Under the influence of testosterone, the bones of the male face become larger and heavier. The muscles and skin are also larger and thicker respectively. Facial hair and a change in the shape of the hairline become apparent in late adolescence.

A. Broader skull
B. More prominent temple bone crest
C. Heavier brow
D. More prominent cheek bone
E. Square chin
F. More sloping forehead
G. Longer skull
H. More prominent brow ridge
I. Heavier jaw angle
J. Larger teeth

The female face also demonstrates secondary sex characteristics which develop in response to the hormone oestrogen. The skin becomes softer and more translucent, more fat develops under the skin, facial hair reduces and the face takes on a softer more feminine appearance.

Anthropometric measurements of the facial skeleton

Frontal view of the female and male face

Lateral view of female and male face

Anthropologists who research anatomical shapes have illustrated and measured the facial proportions of the female and male face. The figures are averages but the images describe the differences in the shape of the average male and female face. Facial feminizing surgery is designed to change the shape and proportions of the male face to look more like the female face. It is important to understand what is possible.

It is evident from the profile view that the face and skull are larger in the male and in particular the lower third of the face is longer and wider. This is because of the greater downward growth of the face in the male compared with the female. The face is wider in the male and the bones thicker with larger muscles and muscle attachments.

It is possible to reshape the brow to make the male brow less masculine, change the shape of the hairline to reduce the temple hairline recession and even lower the hairline using surgery and hair grafts. It is not possible to make the size of the skull smaller but it is possible to soften bony prominences including brow bossing, heavy looking brow ridges, and change the shape of a brow from one which is concave to one which is convex and has soft curves rather than a more masculine angular appearance.

It is possible to change the shape of the nose, the cheekbones and the chin and jawline. But not the maximum width of the face (zy-zy in the illustration), which on average is greater in the female.

WHAT GUIDANCE WILL I RECEIVE FROM A SURGEON

Many transwomen will have given a considerable amount of thought to what they want to do to improve their facial appearance, whereas others will not know where to begin. Either way it is best to see your chosen surgeon with an open mind and ask their advice. There are many different procedures which can help you feel more confident but your surgeon will help you to understand what is possible and formulate a treatment plan to help you reach your goals.

The consultation with your surgeon is probably the most important stage in your treatment because it is not only the surgeon’s opportunity to assess you but more importantly it is your opportunity to assess the surgeon. At your consultation, the surgeon will not only consider your physical requirements and make recommendations but also assess your suitability for surgery. The surgeon seeks assurance that you understand what you are taking on and that you are confident that you understand the potentially life changing treatment that you are consenting to.

Although the process of facial maturation follows the same biological pattern there are of course significant differences between individuals, both physical and psychological. At the end of the day your doctors are helping you overcome your sense of incongruity and it is important that your surgeon can gauge this to enable him to offer you the most appropriate advice and treatment.

In choosing a surgeon it is best that you consult one experienced in facial feminizing surgery with a comprehensive skill set to best enable him or her to advise you on the optimum treatment.

Summary

Faces come in all shapes and level of attractiveness. All transwomen want to have a convincing female face and an attractive one but the latter does not appear to be the main priority. Although the treatment options use surgical techniques which have a lot in common with cosmetic surgery the purpose of facial feminizing surgery is not primarily cosmetic and can be a lot more complex. The medical profession has been slow to understand the difficulties that transgender people have in integrating into society but over the last twenty years there has been a considerable improvement in the number of physicians providing support to the transgender community not least in the number of surgeons providing facial feminizing surgery. However, FFS is still not recognized as a core treatment and as such is not readily available in the NHS.

Hopefully this will change but until then the individual transwoman will have to do their own research to help find a suitable surgeon.